Vaping Related Lung Injury - EVALI - HAN

Vaping-Related Lung Injury

Key messages

It is unknown if patients with a history of e-cigarette or vaping product use associated lung injury (EVALI) are at higher risk for severe complications of influenza or other respiratory viral infections if they are infected simultaneously or after recovering from lung injury. Healthcare providers should emphasize the importance of vaccination against influenza and pnuemococcal disease according to current guidelines.

Healthcare providers should ask patients about use of e-cigarette, or vaping products if they present with symptoms of respiratory or gastrointestinal illness, influenza-like illness (fever and cough/sore throat) or are being reported to public health as an influenza-related ICU admission.

A chest radiograph (CXR) and or CT should be considered for patients who vape and have respiratory or gastrointestinal symptoms.

Providers should test for influenza and consider ruling out other infections for patients with suspected EVALI. Treatment with empiric antimicrobials, including antivirals, should be considered in accordance with established guidelines.

Corticosteroid treatment may be helpful in treating hospitalized patients with EVALI. Consultation with pulmonary and infectious disease specialists should be considered.

Providers should advise patients to stop vaping and link them to appropriate cessation services.

Discharged patinets should be advised to re-present if symptoms recur and followed up within 1-2 weeks.

Outpatient management may be appropriate for some patients with EVALI who have normal oxygen saturations (>95%), no respiratory distress, no cormorbidities that might compromise pulmonary reserve, reliable access to immediate care and strong social support systems. Outpatients should be followed up within 24-48 hours of initial evaluation and advised to seek medical care promptly if respiratory symptoms worsen.

Hold clinical samples of bronchoalveolar lavage (BAL) or lung tissue biopsies after processing and sampling for potential submission to the Illinois Department of Public Health (IDPH) laboratory.

Clinical Presentation

Patients often present with cough, shortness of breath, or pleuritic chest pain. Gastrointestinal symptoms such as nausea, abdominal pain, and diarrhea have been common as well as other constitutional symptoms including fever, chills, weight loss, and fatigue. Diagnostic imaging has demonstrated infiltrates similar to atypical pneumonia on chest x-ray and ground-glass opacities on chest CT, both non-specific findings. Infectious, rheumatologic, and other disease process evaluations are negative. Patients have frequently required intensive care admission and ventilator support due to acute respiratory distress syndrome (ARDS) and hypoxia.

Urinary toxicology screening for patients with significant respiratory illness of unclear etiology in whom a reliable vaping history is unavailable is recommended.

Clinical improvement of patients has been reported with corticosteroid use. Currently there is insufficient outcome evidence to recommend use of steroids on a routine basis. The decision to use corticosteroids should be made based on risks and benefits and the likelihood of other etiologies. Aggressive supportive care is warranted.

Lipoid pneumonia associated with inhalation of lipids generated by e-cigarettes has been reported based on the detection of lipid-laden alveolar macrophages on BAL and lipid staining, though this finding may be present in other illnesses.

Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with pulmonary and infectious diseases specialists as well as pathologists to inform other testing.

No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).

Probable

Using an e-cigarette (“vaping”) or dabbing* in 90 days before symptom onset

AND

Pulmonary infiltrate, such as opacities on plain film chest radiograph or ground-glass opacities on chest CT

AND

Infection identified via culture or PCT, but clinical team** believes this is not the sole cause of the underlying respiratory disease process ORminimum criteria to rule out pulmonary infection not met (testing not performed) and clinical team** believes infection is not the sole cause of the underlying respiratory lung injury

AND

No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).

Note: These surveillance case definitions are meant for surveillance and not clinical diagnosis; they are subject to change and will be updated as additional information becomes available if needed. * Using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette (e-cigarette), vaporizer, vape(s), vape pen, dab pen, or other device) or dabbing to inhale substances (e.g., nicotine, marijuana, tetrahydrocannabinol, tetrahydrocannabinol concentrates, cannabinoids, synthetic cannabinoids, flavorings, or other substances). ** Clinical team caring for the patient.

Prevention

At this time, it is not known what product(s), chemicals or devices are linked to these illnesses.

The CDC recommends the following for patients:

While this investigation is ongoing, if you are concerned about specific health risks, consider refraining from using e-cigarette products.

Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer.

Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products. If you use e-cigarette products, monitor yourself for symptoms (e.g., cough, shortness of breath, chest pain) and promptly seek medical attention if you have concerns about your health. CDC and FDA will continue to advise and alert the public as more information becomes available.

Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you who need help quitting tobacco products, including e-cigarettes, contact your doctor.

Submissions

Submission of BAL or Tissue Samples to IDPH

BAL or tissue specimens can be sent to the IDPH lab on ice packs with a completed IDPH Laboratory Requisition Form. Please indicate outbreak # IL2019-0399 on the submission so that we may correctly assign these samples to this investigation. "Other test" can be marked for type of testing to be performed with the follow up description left blank.